Value PPO

This plan is a High Deductible Health Plan. Use a Health Savings Account (HSA) to set aside the deductible pre-tax.

Plan Benefits

This is a summary of the plan benefits. Complete benefit information is available in the HSA Value Plan Booklet PDF Document and Summary of Benefit Coverage (SBC) PDF Document.

In-Network

Out-of-Network

Group Number 006171

Deductible

$1,400 Member*; $2,800 Family

$1,400 Member*; $2,800 Family

Coinsurance

20%

40%

Out-of-Pocket (OOP) Maximum

$3,000 Member*; $8,000 Family

$6,000 Member*; $16,000 Family

Prescription OOP Maximum

Included in health OOP max

Not Applicable

Wellness Checkup

Covered 100%; procedures covered according to age/sex guidelines PDF Document

Deductible + 40% Coinsurance

Office Visit

Deductible + 20% Coinsurance

Deductible + 40% Coinsurance

Emergency Room Costs

Deductible + 20% Coinsurance

Deductible + 40% Coinsurance

* Individual deductible and out-of-pocket maximums do not apply to family coverage

Immunizations

  • Covered under the Well Child Care provisions for children up to age 16

Routine Mammogram & Pap Smear

  • Covered at 100% in network, 60% out of network. Deductible does not apply

Laboratory Tests and X-Rays

  • Coinsurance after deductible is met

Physical Therapy & Chiropractic Care

  • Coinsurance after deductible is met
  • Member's condition must show continued improvement with physical therapy

Minor Surgery in Doctor's Office or Outpatient Surgical Operations

  • Coinsurance after deductible is met

Diabetes Treatment

  • Covered at coinsurance after deductible is met
    • Self management training services rendered by a physician or licensed health care professional with expertise in diabetes management
    • Regular foot care examinations by a physician or podiatrist

Exclusion Examples

  • Hearings aids; discounts available with TruHearing at 866-687-2020
  • Custodial Nursing Home Care
  • Cosmetic Care except for the correction of congenital deformities or for conditions resulting from accidental injuries, tumors or disease
  • For a comprehensive list of exclusions, contact BCBS at (800) 327-8497

Find a Doctor

  1. Navigate to the Provider Finder
  2. Select the Group health plan and choose PPO

Monthly Premiums

Annual Salary

You

You+Spouse

You+Child(ren)

You+sps+child(ren)

Full Time

Under $42,000

$13

$29

$26

$44

$42,001- $75,000

$27

$60

$51

$90

$75,001- $128,000

$63

$137

$116

$205

$128,001- $182,000

$98

$214

$181

$320

$182,001 and above

$149

$325

$276

$487

Part Time

Under $42,000

$138

$302

$257

$453

$42,001- $75,000

$148

$323

$274

$484

$75,001- $128,000

$172

$374

$317

$561

$128,001- $182,000

$195

$426

$361

$638

$182,001 and above

$229

$500

$425

$750